This application proposes to describe care delivery processes in Missouri nursing homes and the relationship of those care delivery processes, costs of care, and staffing to resident outcomes. Using findings and methods developed in preliminary studies, a three group exploratory descriptive study design will be used to qualitatively describe the processes of care delivery in facilities that have good resident outcomes, to describe how these processes differ in facilities that have average or poor resident outcomes, and to describe exemplar care delivery processes that are associated with good resident outcomes. Additionally, the costs of care, staffing levels, and staff mix in homes with good, average, and poor resident outcomes will be described quantitatively. The relationship of cost of care, staffing level, and staff mix to care delivery processes also will be described. Resident outcomes will be derived from Minimum Data Set for Resident Assessment and Care Screening (MDS) data. Medicaid cost report data will be used to evaluate costs of care, staffing, and staff mix (RN, LPN, NA). The requested FIRST award funding will enable the principal PI to build on substantial preliminary work and undertake this proposed study with the support of an already functioning interdisciplinary research team. Understanding the relationships among processes of care delivery, resident outcomes, costs of care, and staffing is essential to designing organizational interventions that can be implemented in nursing homes to improve quality of care and subsequently improve resident outcomes. This study directly addresses research recommendations from the IOM Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes (1996) that the relationships of staffing levels, skill mix, and quality of care in nursing homes be further explored. With relationships better understood, nursing home providers can adjust their staff-mix and care processes to improve the quality of services delivered. Consumers and their families can be more informed about the importance of exemplar care delivery processes and staffing.